Term
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Definition
| a large vesicle or blister greater than 1cm in diameter |
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Definition
a covering formed from serum drying on the skin |
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Term
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Definition
- flat and nonpalpable change in skin color.
- smaller than 1 cm
- i.e. freckle
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Term
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Definition
- a raised solid lesion that is deeper and larger than a papule
- 1-2cm
- i.e. wart
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Term
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Definition
- a transient elevation of the skin caused by edema of the dermis and capillary dilatation
- i.e. hive, mosquito bite
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Term
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Definition
- a solid elevated palpable lesion less than 1cm in diameter
- i.e. elevated nevus (birthmark)
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Term
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Definition
- a solid elevated lesion on the skin or mucous membrane that is greater than 1cm in diameter
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Term
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Definition
- a lesion that contains pus
- i.e. acne
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Term
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Definition
- heaped up horny layers of dead epidermis
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Term
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Definition
- a small elevation of the skin that is filled with clear fluid
- i.e. herpes, chickenpox
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Term
Compare and contrast common skin problems and related interventions |
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Definition
- Dry Skin- flaky, rough texture
Intervention: bathe less frequently, increase fluid intake, use moisturizing cream to aid healing, add moisture to air (humidifier)
- Acne- inflammatory, papulopustular skin eruption
- Interventions: wash hair and skin with warm soap and water to remove oil; use cosmetics sparingly (oily cosmetics can accumulate in pores and make condition worse); implement dietary restrictions
- Skin Rashes: skin eruptions that result from overexposure to sun or moisture or allergic reactions
- Interventions: wash area thoroughly and apply antiseptic spray or lotion (prevent itching and aid in healing process)
- Contact Dermatitis- inflammation of skin characterized by abrupt onset with erythema, pain and scaly oozing lesions
- Interventions: avoid cauative agents (cleansers and soaps)
- Abrasion- scraping or rubbing away from epidermis that will result in localized bleeding
- Intervention: wash with mild soap and water; avoid scratching patient with jewelry or fingernails; observe dressing or bandage
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Term
| Describe health promotion activities appropriate for clients to prevent the development of impaired skin-integrity |
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Definition
- Skin care- Hygiene and skin care
- Mechanical loading and support devices - Proper positioning and use of therapeutic surfaces
- Education
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Term
| Describe factors that may put a client at risk for development of impaired skin integrity |
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Definition
- Immobilization
- Reduced Sensation
- Nutrition and Hydration Alterations
- Secretions and Excretions on the Skin
- Vascular Insufficiency
- External Devices
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Term
| Describe pathogenesis of pressure ulcers |
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Definition
- Pressure Intensity -If the pressure applied over a capillary exceeds the normal capillary pressure (15-32 mm Hg). Results in tissue ischemia or tissue death.
- Pressure Duration -Low pressures over a prolonged time & high-intensity pressure over a short period time= tissue damage
- Tissue Intolerance -Extrinsic factors (shearing, friction, & moisture) affect skins ability to tolerate pressure -Systemic factors (poor nutrition, increased aging, and low BP) affect the tissue tolerance
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Term
| Compare and contrast the four stages for classification of pressure ulcers |
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Definition
- Stage 1 -Intact skin with nonblanchable redness of localized area
- Stage 2 -Partial thickness skin loss involving epidermis and/or dermis -Ulcer superficial and presents clinically as an abrasion, blister or shallow crater
- Stage 3 -Full thickness skin loss involving damage or necrosis of subcutaneous tissue -Bone, tendon, or muscle are not exposed -Appears as a deep crater with or without undermining of adjacent tissue
- Stage 4 -Full-thickness tissue loss with exposed bone, tendon, or muscle -Undermining and tunneling
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Term
| Discuss the rationale for early, aggressive intervention to prevent pressure ulcers |
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Definition
| Minimizes the impact that risk factors or contributing factors have on pressure ulcer development |
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Term
| Describe health-promotion activities appropriate for clients to prevent development of impaired oral mucous membranes |
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Definition
-Oral hygiene: brushing, flossing
-Keep mucosa well hydrated, minimize foods irritating to tissues, and provide cleansing that soothes and reduces tissue inflammation |
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Term
| Discuss conditions that may put a client at risk for impaired oral mucous membranes |
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Definition
Malnutrition
Chemical trauma |
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Term
| List common hair and scalp problems and their related interventions |
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Definition
1. Dandruff
-Intervention(s): shampoo regularly with medicated shampoo
2. Ticks
-Intervention(s): oil or petrolatum
3. Pediculosis
_Head Lice
-Intervention(s): medicated shampoo, manual removal, vacuum infested areas of home
_Body Lice
-Intervention(s): bathe or shower thoroughly, pediculicide lotion, another bath or shower after 12-24 hours, bag infested clothing, vacuum rooms
_Crab Lice
-Shave hair off affected area, cleanse as for body lice
4. Hair Loss
-Interventions: Stop hair care practices that damage hair (i.e., curlers, tight braiding, and use of hot comb) |
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Term
| Describe factors that influence personal hygiene practices |
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Definition
1. Social Practices
-Family customs
2. Personal Preferences
3. Body Image
4.Socioeconomic Status
-Cost of hygiene supplies
5. Health Beliefs and Motivation
-Knowledge of importance of hygiene; motivation to maintain self care
6. Cultural Variables
-Some cultures only shower 1x week; nurse needs to be non-judgemental
7. Physical Condition
-May lack energy to perform hygienic care |
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Term
| Discuss normal physical findings of the skin, hair and nails in middle-ages adults as compared to an older adult. |
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Definition
Skin
-Middle aged: elastic, well hydrated, firm & smooth
-Older adult: dry (sebaceous glands less active), wrinkled (due to epithelium thinning and shrinking of elastic collagen),
Hair
-Scalp hair becomes thinner and drier with aging
Nails
-more brittles, dull, and opaque and yellow in older adults --cause: insufficient calcium; cuticle also becomes less thick and wide |
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Term
| Nutrients that aid in wound healing |
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Definition
1. Calories
2. Protein
3. Vitamin C
4. Vitamin A
5. Vitamin E
6. Zinc
7. Fluid |
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Term
| Variations in skin color (bluish, red, yellow) |
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Definition
Bluish
-Increased concentration of deoxygenated hemoglobin in blood
Peripheral – cool skin
Central - heart or lung disease - lips, mouth, nails
Assessment of cyanosis in dark-skinned client more difficult
Examine lips, tongue, nail beds, conjunctivae, palms & soles at regular intervals for subtle color changes
Red - erythema
Increased visibility of oxyhemoglobin caused by dilation or increased blood flow
Yellow-orange - jaundice
Increased deposit of bilirubin
R/t liver disease, red blood cell hemolysis
Seen first in sclera, then mucous membranes and generalized |
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Term
| Variations in Skin Temperature (hot, cold) |
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Definition
Cool, cold: Decrease circulation
Hot, warm: Increased circulation
R/T hot shower or hot compresses |
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Term
| Variations in Skin Moisture |
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Definition
Very dry: Characterized by scaling of the stratum corneum. More pronounced over the distal lower extremities
Wet
Perspiration expected with activity |
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Term
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Definition
•Amount of skin elasticity
•Indication of hydration status
•Pinch gently between thumb and forefinger
•Normal - pinched skin returns to place immediately upon release
•Poor - takes 3 seconds or longer for skin to return to its original position
•Normal loss of elasticity with aging makes assessment of skin turgor difficult in elderly clients - with the patient in the supine position the forehead or chest tissue gives the best indication of skin hydration
•Document mobility & turgor
•Pinched skin moves easily and returns to place immediately upon release
can be diminished by edema or dehydration |
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Term
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Definition
swollen from buildup of fluid in tissues;
Skin appears shiny, taut & pale in color
R/t congestive heart failure
Rate the degree of edema – pitting edema is rated on a 4-point scale
• 0 no pitting
• 1+ barely detectable 2mm
• 2+ indentations of 4 mm
• 3+ indentations of 6 mm
• 4+ indentations of more than 8 mm |
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Term
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Definition
Skin tends to stay pinched or tented with dehydration – turgor poor
Document poor - pinched skin tents greater than 2-3 sec. upon release |
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Term
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Definition
characteristics associated with skin cancer
• A - asymmetry of shape
• B - border irregularity
• C - color variation within one lesion
• D - diameter greater than 6 mm
• E - elevation |
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Term
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Definition
small, non-blanchable vascular lesions < 0.5mm diameter
r/t increased capillary fragility |
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Term
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Definition
| bruise, larger areas of hemorrhage which range in size from several mm to many cm |
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Term
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Definition
•Inflammation of subcutaneous tissues
•Common bacterial infection
R/t - infection with streptococci, staphylococci
S&S
•Local - pain, redness, swelling, hot
•Systemic
• Red streaks extending from the patch indicate that the lymph vessels have been infected
• Fever & malaise
• Systemic potentially dangerous but usually can be treated successfully with antimicrobials
Cellulitis on the face must be given special attention because the infection may extend directly to the cavernous sinuses of brain |
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Term
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Definition
Inflammation of the skin.
R/t - various animal, vegetable and chemical substances, from heat or cold, from mechanical irritation, from certain forms of malnutrition, or from infectious disease
-S&S – itching, redness, crustiness, blisters, watery discharges, fissures, or other changes in the normal condition of the skin
-TX – varies r/t cause
•Topical corticosteroids
•Severe systemic steroids
•Avoid irritant
•Antihistamine |
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Term
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Definition
Shingles
-Acute viral disease which is communicable
-Incidence increases with age and degree of host immunosuppression
-Cutaneous eruption estimated to affect 300,000 persons a year in the US
• r/t - reactivation of the varicella-zoster virus (chickenpox)
-S&S
Linear patches along dermatome of grouped vesicles on erythematous base
Usually unilateral and on trunk
Neuralgia preceding outbreak
Mild to severe pain during outbreak
TX
-Symptomatic aimed at relieving the pain and itching
-Local application lotions to dry blisters may help
-Use of the antiviral agent acyclovir can shorten the course of infection and reduce the incidence of post-herpetic neuralgia |
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Term
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Definition
Name applied to many different kinds of fungal infection of the skin
• Tinea pedis – chronic superficial fungal infection of the skin of the foot, especially between toes, on soles
• Tinea capitis – fungal infection of the scalp
• Tinea corporis – fungal infection of the glabrous (smooth & bare) skin |
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Term
| Risk factors for development of pressure ulcers |
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Definition
•Impaired sensory input
•Impaired physical mobility
•Alterations in LOC
•Casts
•Traction
•Various equipment – O2 cannula
Also:
-shearing forces
-moisture
-poor nutrition
-edema |
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Term
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Definition
Is composed of six subscales:
1. Sensory Perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction & Shearing
Total score ranges from 6 to 23. A lower score indicates a higher risk for skin breakdown. |
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Term
| Health promotion for skin |
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Definition
•Limit sun exposure - chronic sun exposure is the single most important factor leading to degeneration of skin components
• Educate anyone with moles or birthmarks to perform periodic skin self-examination and assess for ABCDE's
•Skin survey at 3 year intervals for patients 20 to 40 years of age & annually for patients older than 40 years. |
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Term
| Wound classification is by the color (black, yellow, red) |
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Definition
•Black = necrotic
•Yellow = exudate and yellow fibrous debris
•Red = active healing phase, clean with pink to red granulation & epithelial tissue |
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Term
| Pressure ulcers in dark skin clients |
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Definition
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Term
| Primary Functions of the Skin |
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Definition
Protective function/barrier against:
• Microorganisms
• Ultraviolet radiation
• Loss of body fluids
• Stress of mechanical forces
• Temperature regulation
• Involved in production of vitamin D
• Sensory function
• Touch & pressure receptors provide protective function & pleasurable sensations |
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Term
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Definition
•Symmetrical smile
•Color, moisture, swelling, lesions, signs inflammation
•Pink, moist, symmetrical & smooth, with no evidence of lesions or inflammation
•Pallor
•Cyanosis
Palpation:
Lips should not be flaccid & lesions should not be present |
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Term
| Assessment of Buccal Mucosa |
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Definition
•Color on the inside of the cheek may vary according to race
•African Americans - bluish hue
•Caucasians - pink mucosa
•Glistening, moist, smooth, free of lesions |
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Term
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Definition
•Normally adult has 32 teeth, should be white with smooth edges, in proper alignment & without caries
•Older adults common to see yellow or darkened teeth r/t wear & tear that exposes the darker underlying dentin |
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Term
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Definition
| Pink, smooth, moist with tight margin at each tooth |
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Term
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Definition
•Midline in the mouth
•Dorsum/top medium or dull red, moist, slightly rough on top (due to taste buds)
•Smooth along lateral margins
•Ventral surface pink, smooth with large veins between the frenulum folds |
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Term
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Definition
- solid mass that extends deep through subcutaneous tissue.
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Term
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Definition
Deep loss of skin surface that extenders to dermis and frequently bleeds and scars |
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